COMMENTS: Clean Claims Regulations Public Meeting July 1, 2026

The Maryland Insurance Administration received the below comment letters following the July 1, 2026 Clean Claims Regulations Public Meeting.

Maryland Hospital Association

Marie Grant
Insurance Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, Maryland 21202

Re: MHA Comments on the Clean Claims Regulations

Dear Commissioner Grant:

On behalf of the Maryland Hospital Association (MHA) and its member hospitals and health systems, thank you for the opportunity to comment on Maryland's clean claims and prompt payment regulations following the Maryland Insurance Administration's July 1 public meeting. MHA appreciates the Administration's review of these regulations and looks forward to participating in the Aug. 18 session.

Claims processing has changed significantly since these rules were last amended in 2017. Carriers increasingly rely on automated tools, payment integrity platforms, claim edits, and AI assisted review to process hospital claims. These tools can create efficiencies, but they also underscore the importance of having clear notices and a defined path to collect payment. MHA respectfully offers the following recommendations.

Additional Information Requests and Pended Claims (Insurance Article § 15-1005; COMAR 31.10.11.11)

Under Insurance Article § 15-1005, a carrier must act within 30 days after receipt of a claim by either submitting payment or sending a notice stating why the claim is refused and what information is needed to correct any deficiencies. In practice, however, carriers use additional information requests or a generic “pending” status, which often results in claims being unresolved for extended periods with no justification or explanation. Hospitals are frequently unclear about what additional information is needed to correct the claim. As a result, a claim can remain pending indefinitely. These delays and lack of notice create a significant operational burden, undermine the purpose of the prompt payment statute.

MHA recommends closing this gap in two ways. First, "pending," "under review," and similar terminology should not be treated as a separate claim status that lets a carrier sidestep the 30-day framework. When a carrier needs additional information, it should be required to affirmatively notify the hospital, identify the specific claim and line item at issue, and state precisely what information is needed. Second, a claim should reach a clear endpoint rather than sitting in review indefinitely. If a hospital does not respond within a clearly stated timeframe, the carrier should be required to issue a final claim status notice rather than leave the claim pending indefinitely.

Artificial Intelligence and Automated Claims Payment Tools (Insurance Article §15-1005; COMAR 31.10.11.11 and .14)

Maryland took an important step in 2025 by regulating the use of artificial intelligence, algorithms, and software tools in utilization review. Utilization review and prompt payment operate under different statutory frameworks and address different parts of the payer process. Utilization review focuses on whether a health care service is medically necessary, appropriate, or covered before, during, or after care is provided. Prompt payment, however, governs how a carrier must respond when a claim has been submitted.

Similar to the utilization review, artificial intelligence, algorithms, and software tools are also having a significant negative impact on the claims payment process. They create operational burdens for providers, forcing them to hire additional staff to manage growing volumes of unresolved claims. Hospitals report a sudden and substantial increase in the number of claim reviews per reviewer in recent years. The scale and pace of this increase raise concerns that AI or other automated systems are being used to review claims and inform payment decisions. Without greater transparency and stronger reporting requirements it is difficult to determine whether these systems are being used appropriately or are unnecessarily delaying payment of valid claims.

MHA recommends that MIA require carriers to provide clear notice when an automated tool materially contributes to one of these actions, including the basis for the action, the affected claim or line item, and the precise information needed to resolve the issue. MHA also recommends expanding aggregate claims data reporting to capture claims involving automated tools to assess any increase in instances of downcoding, reductions, and unresolved review statuses.

Downcoding (Insurance Article § 15-1005; COMAR 31.10.11.11; MIA Bulletin 26-9)
MHA strongly supports codifying the standard MIA set in its recent Cigna consent order and in Bulletin 26-9. Those actions make clear that a carrier may not unilaterally change a submitted code to a lower paying code. Instead, a carrier that questions a submitted code should use the prompt payment framework: pay the claim, deny or partially deny it with a specific reason, or request the specific information needed to resolve the issue. MHA requests that MIA codify this standard in the clean claims regulations and identify improper downcoding as a violation subject to penalty and corrective action.

Emergency Department Claim Review (COMAR 31.10.11.13; Health-General § 19-701)
COMAR 31.10.11.13 requires carriers that use auto codes to assess the validity of emergency department claims to disclose those codes to hospitals. The use of auto codes is in tension with Maryland’s prudent layperson standard. This standard requires that emergency claims be evaluated on the patient's presenting symptoms as they reasonably appeared at the time, not on the final diagnosis. An auto code, however, is a diagnosis code. By keying the emergency determination to a set of diagnoses, a carrier necessarily ties reimbursement to the final diagnosis rather than to the symptoms that brought the patient to the emergency department. An auto code alone, therefore, cannot establish whether the prudent layperson standard was met.

As carriers nonetheless use auto codes to evaluate ED claims, MHA recommends that carriers be required to disclose the clinical criteria supporting their ED auto codes in addition to the codes themselves. Requiring disclosure of the underlying criteria alongside the codes would allow hospitals to confirm that the prudent layperson standard was applied and to respond meaningfully when an emergency department claim is pending, reduced, denied, or subject to an additional information request. This would strengthen the existing disclosure requirement and help ensure that emergency department claims are evaluated in a manner consistent with the prudent layperson standard.

Remittance Advice, Claim Notices, and Enforcement (Insurance Article § 15-1005; COMAR 31.10.11; COMAR 31.10.23.01)
Section 15-1005 requires carriers to pay interest on clean claims not paid within 30 days of receipt at escalating monthly rates and to include that interest in any late payment, without the hospital having to request it. That interest obligation protects hospitals only if they can confirm it was met. In practice, however, hospitals often cannot determine whether the required interest was paid. When the accounting of interest is absent or unclear, interest owed by law goes unverified and uncollected, and systemic underpayment is difficult to detect.

MHA recommends that the Administration's regulations require remittance advice, which includes the information hospitals need to confirm compliance with § 15-1005, including payment of interest. The remittance advice should include the date the carrier received the claim, the date of payment, the amount paid or unpaid, and, for any late payment, a separate and itemized accounting of the interest paid, including the rate and the period on which it was calculated. Requiring carriers to identify and itemize interest is a straightforward improvement that reinforces an existing obligation on carriers. It does not change when interest is owed, only whether hospitals can see that it was paid correctly. Where standardized electronic remittance formats apply, carriers should provide any detail not captured in those formats through the accompanying notice. MHA also requests that failure to properly itemize required interest be identified as a violation subject to penalty under COMAR 31.10.23.01.

Working Capital Differential Program
Finally, MHA encourages MIA to work with the Health Services Cost Review Commission (HSCRC) to evaluate the interaction of Maryland's prompt payment protections with HSCRC’s working capital differential program to ensure participating carriers are incentivized to make prompt payments and protect hospitals against the financial disruption that results from delayed payments. Under a working capital differential arrangement, a carrier that advances working capital to hospitals receives a discount on HSCRC-approved rates. Under the longstanding interpretation reflected in Bulletin 99-19, a payer that complies with regulations governing HSCRC’s working capital differential program is treated as having complied with the prompt payment rule for purposes of interest on past due payments. 1 The bulletin also preserves enforcement authority where a payer otherwise violates § 15-1005, refuses to pay a claim, or unreasonably delays payment. MHA encourages the agencies to reassess whether that interpretation continues to provide adequate incentives for prompt claim resolution.

1 See COMAR 10.37.10.26.

MHA appreciates MIA's work to modernize these regulations and welcomes the opportunity to contribute toward specific regulatory language.

Sincerely,

Andrew Nicklas,
Senior Vice President, Government Affairs & Policy
General Counsel

MedChi, The Maryland State Medical Society

The Honorable Marie Grant
Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21202

Re: Clean Claims Notice and Hearing

Dear Commissioner Grant:

On behalf of our client MedChi, The Maryland State Medical Society, and the patients we serve, we appreciate the opportunity to submit comments regarding Maryland’s clean claims law (Section 15- 1005 of the Insurance Article; COMAR 31.10-11.10-.15).

First and foremost, MedChi continues to have significant concerns regarding insurers' failure to pay claims within the timeframes required by Section 15-1005 of the Insurance Article. For example, CareFirst has acknowledged that it has been unable to process and pay claims in a timely manner due to an operational issue. While we recognize this operational issue, it does not relieve it of its statutory obligations. Physicians continue to report unpaid clean claims dating back several months, even back to November 2025, an issue MedChi has raised with the Maryland Insurance Administration. This issue must be resolved expeditiously across all lines of business, and, for those claims subject to Section 15-1005, interest payments must be made.

In addition, MedChi respectfully offers the following recommendations for regulatory consideration:

COMAR 31.10.11.11

Section B states that “[a] third-party may not request additional information if an attachment containing the same type of information was submitted with the claim pursuant to Regulation .10 of this chapter.” This section should be expanded to prohibit an insurer from requesting additional information when that information was previously submitted as part of the prior authorization process or otherwise provided to the insurer before the claim was filed. Requiring physicians to repeatedly submit the same documentation creates unnecessary administrative burden and contributes to delays in claims processing.

COMAR 31.10.11.12

Physicians are often unaware that a specific claim is subject to Maryland’s interest payment requirements because the enrollee is covered by a fully insured health plan. Under this regulation, physicians only receive acknowledgment of a claim “pursuant to a request for claim receipt verification by a health care practitioner.” Consideration should be given to requiring insurers to automatically send a receipt of verification that identifies whether the claim is subject to the protections of Maryland’s clean claims law, including the statutory interest provisions. Likewise, the remittance notice should indicate how many days late a claim is being paid and the amount of interest. Providing this information would enable physician practices to more effectively reconcile payments and verify compliance with Maryland law.

COMAR 31.10.11.14

Insurers are required to submit claims data to the Commissioner twice a year; however, under Section D that information is considered to be confidential commercial information. It is unclear why this data should be confidential. Similar to Maryland’s Appeals and Grievance law, aggregate claims performance data should be publicly available. Greater transparency would improve accountability, assist policymakers in evaluating compliance with Maryland’s clean claims law, and provide valuable information to physicians and the public. We encourage discussions regarding the removal of the confidentiality provision and the integration of the data into the Maryland Medical Claims Data Base, including the development of public reporting mechanisms.

Thank you for considering these comments. MedChi looks forward to continuing to work with the Maryland Insurance Administration to ensure timely claims payment, reduce unnecessary administrative burdens on physicians, and protect access to care for Maryland patients.

Sincerely,

Danna L. Kauffman, Esquire
On Behalf of MedChi

APTA Maryland

July 15, 2026

The Honorable Marie Grant, Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21202

Re: Impact of Delayed Payment of Clean Claims on Maryland Physical Therapy Practices

Dear Commissioner Grant:

On behalf of Maryland physical therapy providers, the American Physical Therapy Association of Maryland (APTAMD), we are writing to express serious concerns regarding the increasing frequency of delayed payment of clean claims by health plans and Medicaid managed care organizations operating within Maryland. We are thankful for your commitment to bring together stakeholders to identify the challenges impacting prompt payment of clean claims. We appreciate MIA hosting public hearings and requesting input from providers as MIA works towards solutions in collaboration with the Adverse Decision Workgroup sessions.

APTAMD acknowledges Maryland's Prompt Pay Law, codified in Insurance Article §15-1005, applies to certain health insurance and managed care payers that operate in the state and handle claims for health coverage. Requiring these carriers to either pay a clean claim or provide a written explanation of the claim's status within 30 days of receipt, and if not paid within 30 days interest payments are required to be paid. The law further requires carriers to specify any information necessary to render a claim "clean", which triggers prompt payment. 1 2

Despite this regulation, physical therapy practices accepting patients from carriers required to comply are experiencing significant payment delays despite submitting complete and accurate claims. These delays create substantial operational and financial burdens on providers who are already facing rising labor, technology, compliance, and administrative costs. Also, these delays are not unique to the carriers but occur with employer-funded and ERISA plans as well.

APTAMD surveyed our membership to gather data regarding carriers’ clean claims payment behavior across the state. APTAMD’s preliminary data from 9 group practices are listed in Table 1. Although 9 practices responded to date, the 9 practices represent thousands of claims submitted on an annualized basis.

Table 1: Clean claims payment delays by payer
(% of respondents reporting payment beyond 15 days)

Payer	0–15 days	15–30 days	>30 days	% delayed >15 days
Medicare Advantage	0%	50%	50%	100%
Tricare/VA	12.5%	37.5%	50%	87.5%
CareFirst	12.5%	50%	37.5%	87.5%
Medicaid	22.2%	44.4%	33.3%	77.8%
UnitedHealth Group	25%	62.5%	12.5%	75%
Medicare	55.6%	22.2%	22.2%	44.4%
Aetna	62.5%	25%	12.5%	37.5%

Physical therapy practices operate on relatively narrow margins and rely heavily on predictable cash flow to maintain patient access to care. When clean claims remain unpaid beyond statutory timelines, practices must absorb the costs associated with clinician salaries, employee benefits, facility expenses, electronic health record systems, compliance programs, and other overhead expenses without the expected reimbursement. The result is increased financial strain, reduced resources available for patient care, and difficulty recruiting and retaining qualified rehabilitation professionals. Also, if the practice is not paid timely or the claims are suspended for no reason, the financial responsibility shifts to the patient to incur the non-payment costs.

Moreover, delayed reimbursement creates unnecessary administrative costs. Staff members must devote considerable time to investigating claim status, resubmitting documentation, responding to repeated requests for information previously provided, filing appeals, and contacting payer representatives. These activities divert resources away from patient care and increase healthcare costs without improving quality or outcomes.

Of particular concern is the frequency with which providers are asked to submit additional documentation long after a claim has been filed, even when the original submission met all stated clean claim requirements. Such requests appear inconsistent with the intent of Maryland's clean claims requirements and undermine the purpose of the Prompt Pay statute, which is designed to ensure timely adjudication and payment of claims. 3 4

The impact extends beyond providers and ultimately affects Maryland beneficiaries. Cash-flow instability can force practices to limit participation with certain payers, delay hiring additional clinicians, reduce service availability, or postpone investments in patient care infrastructure. In underserved and rural communities, these pressures may threaten access to medically necessary physical therapy services for Medicaid recipients, older adults, children with special needs, and individuals with chronic conditions.

We respectfully request that the Maryland Insurance Administration:

1. Increase oversight and auditing of carrier compliance with Maryland's Prompt Pay requirements.

2. Establish a standardized manner to evaluate patterns of repeated requests for documentation on otherwise clean claims which are not in compliance with regulations.

3. Strengthen enforcement actions and/or provide resources to consumers and providers how to follow-up when carriers fail to comply with statutory payment timelines.

4. Increase transparency by publishing payer-specific Prompt Pay compliance data and complaint trends. APTAMD acknowledges denials, adverse decisions, clean claims, and overturn rates are published, but not Clean Claims data processing.

5. Engage providers and professional associations in discussions regarding barriers to timely claim adjudication.

6. Ensure that interest penalties for late payments are consistently applied when required by law when carriers are out of compliance with prompt payment. Physical therapy practices should not have to assume the administrative burden to track down interest payments, file a complaint with MIA, and/or report to State AG before appropriate action is taken.

7. Improve educational resources on the MIA website to assist providers and consumers how to file grievances for carriers not under direct oversight of the MIA, such as reporting to DOH, MHCC, and State Attorney General.

Maryland physical therapists are committed to providing high-quality, cost-effective care that improves function, reduces disability, and helps avoid more expensive medical intervention leading to downstream cost savings. Timely reimbursement is essential to sustaining that mission and preserving patient access to rehabilitation services throughout the state.

We appreciate your attention to this important matter and welcome the opportunity to discuss these concerns further. Thank you for your continued efforts to protect Maryland healthcare consumers and ensure compliance with Maryland insurance laws.

Respectfully, Roy J Film
APTA Maryland President

Zeeshan Bhimani
APTA Maryland
Director for Reimbursement

Cc. Barbara Brocato & Dan Shattuck, Brocato & Shattuck Consulting

1 https://health.maryland.gov/mmcp/provider/Documents/application-addenda/All-Provider-Enrollment-Types-List.pdf

2 https://www.careprecise.com/provider-counts/maryland-healthcare-provider-counts.htm

3 https://health.maryland.gov/mmcp/provider/Documents/application-addenda/All-Provider-Enrollment-Types-List.pdf

4 https://health.maryland.gov/mmcp/Pages/Provider-Information.aspx

Maryland Community Health System

To: Maryland Insurance Administration

From: Salliann Alborn, CEO
Subject: Comments on Maryland Insurance Administration’s Clean Claims Regulations
Date: July 15, 2026

Maryland Community Health System (MCHS) appreciates the Maryland Insurance Administration’s (MIA) efforts to promote timely, accurate, and transparent claims processing. MCHS is a Health Center Controlled Network of federally qualified health centers (FQHCs) providing primary medical, behavioral health, and dental care to underserved communities across Maryland. The clean claims regulations provide an important framework for ensuring that federally qualified health centers (FQHCs) are reimbursed appropriately and that payors maintain reasonable processes for reviewing claims.

During the July 1st meeting, the MIA provided a brief history of the current regulations (COMAR 31.10.11.10 through 31.10.11.14) as well as an overview of the statutory authority under Insurance Article §§15-1003 through 15-1005. At the end of the presentation the MIA posed four questions for stakeholders to comment on:

Which provisions of regulations are outdated, and how should they be updated? • Does the list for attachments to be considered a clean claim require updating?
Does the list of permissible categories of disputed claims for which additional information may be requested require updating? • Should the MIA resume issuing a Clean Claims Data Report with de-identified and aggregated data?

FQHCs operate as safety-net providers delivering integrated, team-based care that includes primary medical care, behavioral health services, dental care, enabling services, care coordination, and other supportive services. FQHC reimbursement is also governed by specialized payment methodologies, including the Medicare and Medicaid Prospective Payment System (PPS) structures, rather than traditional fee-for-service reimbursement models. As a result, claims-processing requirements developed primarily around individual professional services or procedural billing do not always align with FQHC operations. We recognize that certain Medicare and Medicaid reimbursement requirements may fall outside the MIA’s direct jurisdiction. Nevertheless, those payment methodologies shape FQHC billing operations, and the clean-claims regulations should account for those operational realities where MIA has authority. Updating certain part of COMAR 31.10.11.10–31.10.11.14 would reduce unnecessary administrative burden while maintaining appropriate safeguards against improper billing and fraud.

Which provisions of regulations are outdated, and how should they be updated? (COMAR 31.10.11.12 — Receipt of a Claim)

The claim-receipt provisions should be modernized to reflect the current electronic claims practices as well as to algin with how Maryland has moved to updated prior authorization and appeals and grievances processes. Currently, FQHCs submit the vast majority of claims electronically through payor portals. The existing regulations focus on mailed claims, courier delivery, and batch receipt processes and do not fully address modern claims submission practices.

The regulation should require payors to provide timely electronic confirmation of claim receipt, including acknowledgment that the claim was received, accepted, or rejected. Once a claim has been successfully transmitted and accepted by a clearinghouse or payor system, the claim should be considered received for purposes of applicable payment deadlines. Providers should not bear the burden of disputes regarding internal payor processing failures after electronic acceptance has occurred. Similar to the prior authorization statute, the regulation should also require payors to provide accessible claim status information, including claim tracking identifiers, processing status, and reasons for delays or rejection.

COMAR 31.10.11.10 should also be modernized to replace outdated references to the HCFA Form 1500 and UB-92 with the current CMS-1500 and UB-04/CMS-1450 claim forms, as applicable. The regulation should recognize current HIPAA-compliant electronic transaction standards for professional, institutional, and dental claims, including applicable successor forms and standards. To prevent future obsolescence, the MIA should recognize federally adopted successor forms and transaction standards while preserving uniformity and prohibiting payors from requiring proprietary claim forms, data elements, or attachments beyond those authorized by law or regulation.

Does the list for attachments to be considered a clean claim require updating? (COMAR 31.10.11.10 — Attachments to Uniform Claims Forms)

The current attachment requirements under COMAR 31.10.11.10 is primarily focus on procedure-based claims, including requirements involving operative reports, or anesthesia records. While these requirements may be appropriate in some circumstances, they do not fully reflect the encounter-based and integrated care model utilized by FQHCs. FQHC claims could represent comprehensive patient encounters involving multiple services rather than a single isolated procedure.

The regulation should be updated to establish that payors may not routinely require medical records, treatment plans, or other attachments for FQHC claims unless the request is related to a specific, documented issue involving payment, coverage, coding, medical necessity, or fraud. Consistent submission of clinical records with every FQHC claim creates significant administrative burden, and increases costs, without necessarily improving claims accuracy. The regulation should also expressly prohibit blanket or repetitive documentation requests and encourage payors to use targeted audits, provider education, and corrective action processes when additional review is necessary.

Does the list of permissible categories of disputed claims for which additional information may be requested require updating? (COMAR 31.10.11.11 — Additional Information)

Yes, COMAR 31.10.11.11 provides important protections against inappropriate claim delays; however, additional safeguards are needed to prevent broad or nonspecific documentation requests from becoming a mechanism for delaying payment, a tactic MCHS believes already occurs today. FQHCs frequently experience claim delays related to payor-specific interpretations of billing requirements, authorization processes, and provider enrollment issues.

The regulation should require payors requesting additional information to identify with specificity the claim element in question, the reason the information is necessary, the applicable regulatory or contractual basis for the request, and how the requested information will affect claim adjudication. Additionally, the MIA should consider revising this regulation to shift the burden by presuming that claims are clean unless the payor identifies a specific deficiency. This approach would preserve the payor's authority to review claims while preventing unnecessary delays resulting from generalized or non-specific requests for additional information. The regulation should also prohibit payors from requesting information that has already been provided unless the payor identifies a material deficiency in the previously submitted documentation.

Should the MIA resume issuing a Clean Claims Data Report with de-identified and aggregated data? (COMAR 31.10.11.14 — Claims Data Filing)

Yes, MCHS strongly supports resuming publication of a de-identified and aggregated Clean Claims Data Report. The current claims-data reporting requirements provide important oversight but do not capture the specific challenges faced by FQHCs. Reporting focused solely on overall clean claims rates, additional information requests, and payment compliance does not adequately identify whether claims-processing practices create disproportionate administrative burdens for certain provider types or certain care settings.

The regulation should require claims reporting to include provider-type specific data, and specific care setting data, which would include FQHCs. Payors should report information regarding claims volume, percentage of clean claims paid within the statutory timeframe, average time to payment, frequency of documentation requests, claims suspended for review, denial categories, and appeal outcomes. These additional data elements would allow the MIA to identify trends, monitor whether payors are applying appropriate claims-processing standards, and evaluate whether administrative practices are creating barriers to the financial stability of safety-net providers.

Thank you again for the opportunity to submit these comments. If we can provide any additional information, please contact me at [email protected] or our policy consultants, Robyn Elliott and Michael Paddy at [email protected] and [email protected].